Post on 12-Feb-2016
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Practical Aspects of Insulin Pumping
DeAnn Johnson, RN, BSN, CDESusie Owen, RN, CDE
Overview:
Evidence for pump therapy Patient selection Dosing Set and site issues Pump attire Sick Days Travel Case study Discussion
BDC results:1 year pre CSI compared to ea yr thereafter
*= p<0.001, †=p<0.05. The pre-CSII values for each year represent the initial values for only those with an HbA1c value in that year.
HbA1c Values(1 year pre-CSII compared to each year)
6.5
7
7.5
8
8.5
9
1 2 3 4 5 6 7 8
Years on CSII
HbA
1c v
alue
(%)
Pre-CSII
Most Recent
* * † † ††
† †
n=291 n=267 n=196 n=146 n=105n=59
n=34 n=11
Chase HP et al, Diabetes Technology& Therapeutics, 9:421,2007
Figure: The Decline of Severe Hypoglycemic Events with CSII Therapy in a General Clinic Population
02468
101214
Pre-CSII On CSII Pre-CSII On CSII
Rat
e of
hyp
ogly
cem
ia
(eve
nts
per 1
00 p
atie
nt-
year
s)
* **
Severe Hypoglycemia and Insulin Pumps (CSII)
* Maniatis, Chase, et al. Pediatri,107,351 2001
(In DCCT: 62per 100 pt. yrs: NEJM, 329, 977, 1993)
** Scrimgeour, Chase, et al D T & T 9:421, 2007
Who’s a good candidate?
Essential Criteria for Pump InitiationSurvey of 54 Diabetes Educators
Lenhard et. al., Infusystems USA 3, 1, 2006
* All 54 respondents ranked SMBG as an essential criteria for pump start
2007 Consensus Statement on Pump Use in Peds- Patient SelectionEndorsed by the ADA & European Assoc. for the Study of Diabetes
Recurrent severe hypoglycemia Wide fluctuations in bg levels regardless of A1c Suboptimal diabetes control Micro/macro vascular complications Good control but regimen compromises lifestyle Infants and neonates Adolescents with eating disorders Children and adolescents with pronounced dawn
phenomenon Pregnant adolescents Ketosis-prone individuals* Competitive athletes Children with needle phobia**
Battelino,P.M., Rodriguez,H.D., Kauffman, F. Use of insulin pump therapy in the pediatric age-group: consensus statement from the European Society for Paediatric Endocrinology, the Lawson Wilkins Society and the International Society for Pediatric and Adolescent Diabetes, endorsed by the American Diabetes Association and the European Association for the study of Diabetes Care Diabetes Care 2007:30:, 1653-1662
*Blackett PR: Insulin Pump Treatment for Recurrent Ketoacidosis in Adolescence; Diabetes Care;1995;18:891-892.
**Maniatis AK et al, Pediatric Diabetes 2001 June;2(2):51-57.
Basal Dosing Half total daily dose. May decrease by 10-30%. Divide over
24 hours
Convert Lantus or Levemir dose directly into basal
Set pump up in 3 hour increments
Consider dilution to U50 (off label) if using <.05 u/Hr. To order diluent for Humalog 1-800-821-0538, for Novolog
1-800-727-6500
Keep timing of basal dosing in mind for disconnections
Use alternate increased basals for menses, illness, steroid use and alternate lower basals for high exercise days/nights
From Holterhus PM, et al., Diabetes Care, 2007; 30(3):568-73.
B and C= 708 and 83 primarily pubertal subjectsD = 152 subjectsF = 117 pre-pubertal subjects
Basal Dosing Needs
Bolus Dosing Consider using “Rule of 500 (carbs)
& Rule of 1700 (correction)” Bolus 15-30 minutes prior to meal
Mean change in blood glucose levels following four methods of bolus administration. (Chase HP et al. Diab Med 19:317, 2002.)
-1
0
1
2
3
4
5
1 Bolus 2 boluses Square wave Dual Wave
Method of bolus administration
Chan
ge in
blo
od g
luco
se le
vels
(mm
ol/L
)
2-hour post-prandial4-hour post-prandial
Dual Wave Bolusing
Use of the Combination or Dual Useful for all high fat/ high carb meals
May add a unit to total bolus to combat decreased insulin sensitivity
Starting point: Take ½ (50%) of bolus immediately and extend the other half (50%) over the next 2 hours
Check bg at 2,4 and 6 hours
Make adjustments as needed (examples): > 180* at 2 hrs. = to 60% Immediate bolus < 70* at 2 hrs. = to 40% Immediate bolus > 180* at 4 hrs. = to 60% Extended bolus
*180mg/dl =10mmol/L
Forgotten Boluses –Increase of a half point in A1c if just 2 boluses missed per week!*
Use of pump alarms Cell phone alarm “Food in mouth, hand
on pump!” Upside down plate Bolus for all carbs
(except tx of lows) Parental review Evaluate for eating
disorder
*Chase HP, et al: Pediatrics 113,221,2004
Jason Johnson, a pitcher for the Detroit Tigers was diagnosed with Type 1 Diabetes when he was 11.
The MLB approved use of insulin pumps during games in 2004.
Exercise
Exercise Dosing
Disconnect for duration. Test every 2 hours minimum. May need 50% bolus pre-disconnection for anticipated missed basal + correction and additional corrections throughout activity.
25-75% decreased temp basal during moderate to intense extended duration activity. May start up to an hour prior.
25-75% reduction to alternate basal for delayed hypoglycemia during the night starting 2 hours prior to expected drop.
Potential 25-75% decrease to bolus just prior to activity and/or immediately following.
Choosing the Right Site and Set
Site and Set Considerations
Pinch test Hypertrophy/lipo-
atrophy Curves Disconnection access Diapers Activities
90 Degree Infusion Sets
Cleo
InsetSure T
Quick set
Rapid D
Angled Infusion sets
Inset 30
Omnipod
ComfortSilhouetteTender
Minimize Pain and Anxiety
Desensitization:breathing/ distraction/ visualization –bubbles, I Pod
Use of inserter Use of buttock/hip Parent wears at
saline start Respect rituals
Maniatis AK et al, Pediatric Diabetes 2001 June;2(2):51-57.
Numbing agents
ice – teething rings, cold stones
Gigi Waxing Spray
L-M-X4
Emla crème, generic lidocaine 2.5% /prilocaine 2.5% crème (discs or use with wax paper)
Where to wear?
alana-mireilleapparel.com
Kangaroo Pump Pockets
Mypumpgear.com
Pumpwearinc.com
store.minimed.com
Wearing the Pump
Cell Phone/PDA Holders as Pump/PDM Holders
Making it Stick (or not)
Antiperspirant Skin Prep, IV Prep,
Bard wipes Skin Tac / Tac Away Mastisol / Detachol IV3000,Tegaderm
Polyskin, Water proof sports tape
STR Surgical and Sports Tape Remover
Sick Days
Test blood or urine ketones if >300 or >240 twice
Give a shot and change set if positive
Increase fluid intake Use of temp basal Extra tape to site for surgery
Vacations
10-50% reduction in dosages
Travel letter and current dosing
Take along “loaner pump” and/or basal insulin & syringes
More frequent set changes